Boatswain's Mate 3rd Class Travis Obendorf died in a Seattle hospital Dec. 18 as a result of injuries he sustained during search-and-rescue operations near Amak Island, Alaska, on Nov. 11 while serving aboard cutter Waesche. (Coast Guard)

Dangerous conditions and complacency led to the death of a Coast Guardsman following a rescue mission north of Alaska last year, according to a recently released Coast Guard investigation.

Boatswain’s Mate 3rd Class Travis Obendorf, 28, became pinned between a recovery net and the center console of his 25-foot recovery boat Nov. 11 when a swell pushed the vessel forward. He was in an area where crew members aren’t supposed to be stationed, according to the report, but was there because a piece of rescue equipment wasn’t working properly.

He died of a head injury a month later, Chief Warrant Officer 2 Allyson Conroy, a Coast Guard Pacific Area spokeswoman, confirmed in December.

Obendorf, a nine-year veteran, was assigned to the national security cutter Waesche, based in Alameda, Calif.

As the recovery boat entered the cutter’s stern notch to transfer eight passengers, a swell surged the recovery boat forward, according to the incident report, the release of which was announced in an April 3 ALCOAST message.

Rather than bump up against the capture net stretched across the cutter’s stern notch, the boat’s bow was forced under the net, stopping only when the net hit the center console, with Obendorf trapped in between.

A Coast Guard helicopter crew transported him to Cold Bay, Alaska, for a commercial medevac flight to Anchorage, about 600 miles away.

Obendorf’s family came to Anchorage to be with him in the days following the accident, before he was transferred Dec. 6 to Seattle.

“Petty Officer Obendorf’s selfless actions directly contributed to rescuing five mariners in distress,” Waesche commander Capt. John McKinley said in a news release.

Witness accounts said Obendorf was trapped twice by the net, but was uninjured the first time. He wasn’t supposed to be standing at the front of the boat during the passenger transfer, but Waesche’s crew had been placing someone in that position to overcome an equipment deficiency.

The cutter’s capture line is designed to automatically attach to a “horn” on the bow of the recovery boat, connecting the two. According to the investigation, Waesche’s capture line never worked consistently, so the crew put a member at the front of the boat to connect it manually.

The second cause of the mishap had to do with the crew’s comfort level operating in unstable weather conditions, the report found.

The crew never had a problem in 130 prior launch-and-recovery operations, despite Alaska’s choppy waters, so the conditions Nov. 11 didn’t strike any of the key personnel as dangerous. However, they were operating outside of published safety limits, the report found.

There will be some changes to launch-and-recovery operations going forward, Conroy told Navy Times on April 16.

“With regards to the equipment, there has been a configuration and material change to the stern capture system on all of the national security cutters to reduce the risk of this happening in the future,” she said.

Prior to the Waesche incident, the capture net sat about four feet above the stern notch’s ramp — just enough space for the bow of a recovery boat to move underneath it. The net has been lowered to avoid that problem.

“The Coast Guard has also issued guidance that advises commanding officers not to place crew members forward of the center console during small-boat recovery operations,” Conroy added.

Obendorf was originally from Idaho Falls, Idaho. He was single with no children. His previous assignments included the medium endurance cutter Alert, Patrol Forces Southwest Asia in Bahrain and Coast Guard Station Boston.